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Genetic Testing

Provider Type

  • Physicians
  • Participating Physician Groups (PPG) 
    (does not apply to HSP)
  • Hospitals
  • Ancillary

In general, Health Net covers genetic testing when medically necessary and all of the following are met:

  • The member has personal or family history features suggestive of an inheritable condition
  • The test can be adequately interpreted
  • The results of the test will aid in diagnosis or directly impact the treatment being delivered to the member or family
  • Sensory impairment, especially if accompanied by any of the above indications

Medically necessary genetic testing is covered for the following conditions:

  • Tay-Sachs disease (TSD)
  • Von Hippel-Lindau disease (or syndrome)
  • Huntington's disease (HD)
  • Hereditary nonpolyposis colorectal cancer (HNPCC)
  • Cystic fibrosis (CF)
  • Breast cancer (BRCA)
  • Long QT syndrome (LQTS)
  • High-risk pregnancies
  • Pregnancy abnormalities:
    • Maternal serum alpha-fetoprotein
    • Maternal serum triple screen
    • Ultrasound examination
    • Chorionic villus sampling (CVS)
    • Amniocentesis for women age 35 or older

    Prenatal or preconceptional genetic counseling for members or couples is also covered.

Indications for Covering Genetic Testing

Health Net covers medically necessary genetic testing for any of the following:

  • Unexplained developmental delay or mental retardation
  • Unusual facial appearance or other dimorphic features, especially accompanied by failure to thrive or sub-optimal psychomotor development
  • Movement disorder
  • Positive newborn screen, for example, phenylketonuria (PKU), congenital hypothyroidism, congenital adrenal hyperplasia (CAH), biotinidase deficiency, maple syrup urine disease, galactosemia, homocystinuria, sickle cell anemia, medium chain acyl-CoA dehydrogenase deficiency (MCAD), or hearing loss
  • Common birth defects, such as cleft lip or palate, neural tube defects, clubfoot, congenital heart disease, or congenital kidney defect
  • Known or suspected metabolic disorder, including symptoms, such as failure to thrive, organomegaly or loss of previously acquired developmental milestones, as well as occurrences of neonatal death
  • Abnormal sexual development, primary amenorrhea, aspermia, infertility, or multiple miscarriages
  • Ambiguous genitalia
  • Growth retardation or failure to thrive
  • Sensory impairment
  • Two or more close relatives with the same disease or related diseases, such as cancer, mental illness or neurologic disorders
  • Familial cancer (for example, retinoblastoma, Wilms' tumor, renal carcinoma, optic glioma, or acoustic neuroma)

Exclusions and Limitations

For additional information, including exclusions and limitations of genetic testing, refer to Health Net's national medical policies online at the provider portal at provider.healthnet.com site.

Last Updated: 11/05/2019